Provider Demographics
NPI:1912358730
Name:MARTELL, SUSANNAH (NP)
Entity Type:Individual
Prefix:
First Name:SUSANNAH
Middle Name:
Last Name:MARTELL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:ZANNAH
Other - Middle Name:
Other - Last Name:MARTELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:1776 SW MADISON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-1715
Mailing Address - Country:US
Mailing Address - Phone:503-224-1044
Mailing Address - Fax:503-621-2235
Practice Address - Street 1:703 NE HANCOCK ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-3955
Practice Address - Country:US
Practice Address - Phone:503-230-9875
Practice Address - Fax:503-331-3441
Is Sole Proprietor?:No
Enumeration Date:2016-06-22
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR099000190RN163W00000X
WARN61068677163W00000X
OR201606933NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500716952Medicaid